Recommended First Dose of Sumatriptan for 2-Day Migraine
For a patient with a 2-day migraine, start with oral sumatriptan 50-100 mg at the onset of treatment, though the medication should ideally have been taken much earlier when pain was still mild for optimal effectiveness. 1, 2, 3
Initial Dosing Strategy
The FDA-approved oral dosing options are 25 mg, 50 mg, or 100 mg, with 50 mg and 100 mg providing greater effect than 25 mg. 3 The American Academy of Family Physicians recommends oral doses of 50-100 mg at migraine onset. 1
- Start with 50 mg if the patient has never taken sumatriptan before to balance efficacy with tolerability, as this dose has the best effectiveness-to-tolerability ratio. 4
- Consider 100 mg for patients who need more aggressive treatment or have previously failed lower doses, as 35% of patients prefer this dose due to superior efficacy and speed of action. 4
- The 100 mg dose achieves complete pain relief in approximately 28% of patients at 2 hours compared to 11% with placebo (NNT 6.1). 5
Critical Timing Consideration for This Patient
A major caveat: sumatriptan works best when taken early in the migraine attack when pain is still mild. 2 For a patient presenting with a 2-day migraine, the medication is being started late in the attack, which significantly reduces treatment success. 2 This patient should be counseled that:
- Future attacks should be treated immediately at onset, not after 2 days. 2
- Taking medication when pain is moderate or severe (as in this case) reduces effectiveness compared to early treatment. 2
Repeat Dosing if Needed
If the migraine has not resolved by 2 hours after the first dose, or returns after initial improvement:
- A second dose may be given at least 2 hours after the first dose. 3
- Maximum daily dose is 200 mg in any 24-hour period. 1, 3
- Approximately 40% of patients experience headache recurrence within 8-12 hours, which responds well to a second dose. 1, 2
Alternative Routes for Faster Relief
If oral administration is inadequate or the patient needs faster relief:
- Subcutaneous 6 mg provides the fastest relief (within 15 minutes) with highest efficacy (70-82% response rate), compared to 2 hours for oral. 1, 2
- Intranasal 5-20 mg is an intermediate option with faster onset than oral but slower than subcutaneous. 1
Important Trial Period
The patient must try sumatriptan for 2-3 separate migraine episodes before determining if it is effective. 2, 6 A single failed attempt, especially when taken late in the attack, does not mean the medication won't work for future attacks treated earlier.
Absolute Contraindications to Screen For
Before prescribing, ensure the patient does NOT have: 2, 6
- Coronary artery disease, previous MI, or Prinzmetal angina
- Hemiplegic or basilar migraine
- Uncontrolled hypertension
- Current MAOI use or use within 2 weeks
- Use of ergotamine derivatives or another triptan within 24 hours
- Severe hepatic impairment (if mild-moderate hepatic impairment, maximum dose is 50 mg) 3
Medication Overuse Warning
Limit sumatriptan use to no more than 4 headaches per 30-day period to avoid medication overuse headache. 2 This is particularly important for a patient presenting with a 2-day migraine, as frequent triptan use can perpetuate chronic headache patterns.
Combination Therapy Option
If monotherapy provides insufficient relief, combine sumatriptan with a fast-acting NSAID or acetaminophen. 2 This can be considered for this patient given the prolonged duration of the current attack.